Care Home: REACH Lower Cippenham Lane

What the care home does well This is a well run home where residents say that they are happy with the care they receive and staff are `kind` and `caring`. The home is good at making sure residents can say what they like to do and they are always given a choice. A wide range of activities are on offer and most of the residents enjoy an active lifestyle. Many attend college, day centres and various clubs and societies. All residents are offered the opportunity to take an annual holiday supported by staff. There are enough staff on duty at all times to meet the needs of residents. Recruitment practices are well carried out and the staff files contain essential information to ensure residents are kept safe. Staff are well trained, caring and committed. The written records are well kept and up-to-date and provide the staff with the information they need to provide the right care. Residents are fully involved in their care and feel their opinions are valued and listened to. The home is comfortable and clean. All residents have a highly personalised bedroom which are decorated and furnished to their own particular choice and preference. Residents feel that they have a say in how the home is run on a day-to-day basis. They say that Management are `approachable and kind`. They feel that their views are taken into account at all times. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: REACH Lower Cippenham Lane 178 Lower Cippenham Lane Cippenham Slough Berkshire SL1 5EA two star good service The quality rating for this care home is: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Julie Willis Date: 1 4 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to:  Put the people who use social care first  Improve services and stamp out bad practice  Be an expert voice on social care  Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Internet address www.csci.org.uk Information about the care home Name of care home: Address: REACH Lower Cippenham Lane 178 Lower Cippenham Lane Cippenham Slough Berkshire SL1 5EA 01628666132 01628666132 cippenham@reach-disabilitycare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): R.E.A.C.H. Ltd Name of registered manager (if applicable) Miss Suzie Marie Houlton Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 12 0 care home 12 learning disability Additional conditions: The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either Whose primary care needs on admission to the home are within the following category/ies Learning Disability - Code LD The maximum number of service users who can be accommodated is 12. Date of last inspection Brief description of the care home: 178 Lower Cippenham Lane offers twenty-four hour residential care to twelve, male and female residents who have a diverse range of learning and associated disabilities. The home is owned by REACH Ltd. Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home How we did our inspection: This key inspection of the service was an unannounced visit to the home on the 14th October 2008. The inspector was in the service from 10:00am to 3:30pm. It was a thorough look at how well the service is doing. It took into account detailed information provided by the services Manager and any information that the CSCI has received since the last inspection which took place on 24th October 2007. Prior to the visit a questionnaire was sent to the Manager along with surveys and comment cards for residents, staff and Care Managers. The replies were used to help form judgments about the service. Consideration has been given to other information that has been provided to the Commission since the last inspection. The inspector toured the home, examined records and met most of the residents. The inspector spoke at length to four residents that had asked to see her. The inspector also spent time observing how care was being delivered to residents. From the evidence seen and comments received the inspector considers that this service would be able to provide a service to meet the needs of people with various religious, racial or cultural needs. This service is good at meeting the needs of residents with a range of diverse needs and actively promotes equality and anti-discriminatory practice for people with disabilities. The Commission has received no information about complaints about this service. There has been one safeguarding adult incident that has been notified to the CSCI since the last inspection. The inspector gave feedback about her findings to the Manager at the end of inspection. There were no requirements arising from this inspection however, the Manager did undertake to take remedial action to rectify several deficits during the inspection visit. The cost of this service ranges from 706.29 to 1546.35 per week. What the care home does well: What has improved since the last inspection? Since the last inspection several bathrooms have been refurbished to improve the environment for residents. Since the last inspection the rosters have improved to provide more staff at busy times of the day. This has made it it easier to support residents to participate in evening activities. Several staff have undertaken language skills training to improve their spoken and written English. This has improved their communication with residents and other staff. What the care home could do better There are no new requirements arising from this inspection. The Manager undertook to remedy deficits at the time of inspection. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line - 0870 240 7535 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Services are centred on the needs, wishes and views of those who use them. Potential users of the service have clear information to help them choose a service that meets their needs. Evidence: There is sufficient information available in varying formats to enable potential users of the service to decide if the home can effectively meet their needs. The Statement of Purpose and Service User Guides contain all information required by Regulation and Standard. The information has been made available in a pictorial format to aid understanding. Service users confirmed in surveys and discussions that they had been consulted about their move to the home. Most of the current residents moved to Cippenham Lane when their previous home closed. From discussion with staff and management it is clear that all residents were fully assessed prior to admission using a comprehensive tool designed for the purpose. Information was collated from a range of sources and the decision to place individuals at the home was carried out by a multi-disciplinary team of professionals in conjunction with the resident and their family. Most service users lived together at another home prior to moving to Cippenham Lane. Discussion with people using the service evidenced that the management of the transition from one home to another had been carried out professionally and with sensitivity. The residents had been introduced to their new home in a planned manner which gave residents time to adjust and familiarise themselves with the routines of the Evidence: home , the staff team and other residents. After the residents had settled into their new surroundings a review was carried out which involved the Care Manager, health professionals, staff, family members and the resident themselves. Several residents commented to the inspector that they liked living at the home. They said, Staff are very good here, they look after me well, I moved here when my other home was closed, its lovely, much better than before. Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Individuals are involved in decisions about their lives and play an active role in planning their care and support. Evidence: Examination and case tracking of six peoples care evidenced that the records were upto-date and well documented. It was evident that the staff have tried to involve people that use the service in the care plan process from the outset and their input was clearly documented in files. The care files were comprehensive and holistic in detail and provided sufficient information for staff to provide appropriate care. New user friendly Person Centered Plans (PCPs) were introduced in September 2007. Their introduction has been particularly successful as residents enjoy showing others their PCP and updating the information contained in it with their key worker. Those examined were well put together and up-to-date with photographs and other memorabilia to personalise them. Discussions with people that use the service confirmed that they had helped to write the care plans and had agreed the content with their key worker. The home carefully follows the the principles of person centered planning and involve residents in all aspects of their care. Personal programs and goals had been jointly agreed between the staff and residents and goals appeared realistic and achievable. From examination of documentation and discussion with staff it was evident that the home positively encourages people to develop life skills and independence. This has led to a degree of risk taking. The content of files evidenced that people are supported Evidence: to take risks as part of their everyday lifestyle and to experience new things. These risks have been fully risk assessed and guidelines are in place to minimise the risk to residents. The risks associated with bathing, falls, use of laundry, use of kitchen, transportation and risk to the person of displaying challenging behaviours were well documented. Any limitations on an individuals freedom had been agreed with the resident. People are fully supported to make decisions about their everyday lives . People choose when to rise and retire, when to be in company or alone and when they want to go out. A number of the residents regularly stay with family at weekends or during holidays. People are encouraged to make new friends and to develop and maintain personal and intimate relationships. Residents confirmed that they are encouraged to express choice and make decisions. One resident said, There are no limits we can do as we please, Staff never make me do anything that I dont want to do. Residents confirm that they are supported to manage their own money and to make choices about how they spend it. One resident said, Ive got new bedroom furniture, I chose what I wanted, its much nicer than the old stuff. The home regularly meets with residents to ascertain their wishes and preferences. Minutes of these meetings confirmed that they were entirely user led and focused. Where action was required by staff or management following a meeting there was evidence that appropriate action and resources had been provided in a timely manner. Feedback from seven service user surveys indicated that people using the service were very happy with the quality of care they were receiving. One resident said, It is very nice and staff are brilliant another survey response said, The carers always listen to my opinion, staff treat me well. Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People that use services are able to make choices about their lifestyle and are supported to develop life skills. Social, cultural, educational and recreational activities meet individuals expectations. Evidence: Examination of care plans, daily records and discussion with staff and residents evidenced that residents are encouraged and supported to lead meaningful lives. The home promotes citizenship and the rights of residents to enjoy an ordinary life. All service users are provided with the opportunity to engage in activities that are stimulating and worthwhile. They make good use of communal facilities including local restaurants, bowling alleys, cinemas, sports facilities and public houses. All of the residents access the community using taxis, public transport or the house vehicle. Several residents attend local day centres where they are encouraged to engage in group activities or one-to-one sessions. Peoples attendance is well documented and their progress toward agreed goals form part of their formal review. It is evident that people are positively encouraged to engage with the community and are supported to learn new skills at local colleges. One resident told the inspector that they went to cookery and pottery classes whilst other residents attended popular culture, sound rhythm & music, arts and crafts and photographic and multi-media lessons. Evidence: At home residents are involved with the shopping, cleaning and laundry activities. Residents also do cooking at the home closely supervised in the kitchen by staff. These activities form part of the persons individual care plan. Whilst at home residents were observed to listen to music, watch television or DVDs or to go for walks with friends or the staff. People at the home are encouraged to be part of the broader community and several residents attend a local church. Residents also attend local clubs run by charities or community organisations. Two residents said that they were looking forward to their weekly visit to the local Royal British Legion club that night. One resident said that he liked to go to the Thursday Mencap club and particularly enjoyed it when they had a discotheque. Most residents choose to take an annual holiday. One of the residents said they went to stay in a cottage in Devon and another said that they had visited the Norfolk Broads. Residents are positively encouraged to maintain their relationships with family and friends and several residents said that they stayed with family at weekends. The home provides a nourishing menu, which meets the cultural needs of residents. In the summer residents grew their own produce in the garden and the fruits and vegetables grown were incorporated into the weekly menu. Residents are provided with choice and variety and regularly consulted about the menus. Mealtimes are considered a social occasion in this home and residents are encouraged to eat together in the dining rooms. Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The health and personal care that people receive is based on their individual need. The principles of respect, dignity and privacy are put into practice. Evidence: From examination of care records it is evident that residents physical and personal care needs are well met by the home. All care and support provided to individuals is well documented in the daily records. Staff ensure that personal support is flexible, consistent and responds to the changing needs of residents. All residents are supported sensitively and discreetly and are encouraged to develop and remain independent by showering and bathing in privacy except where staff supervision is deemed necessary for the maintenance of a residents safety. Residents confirmed that all care is provided in a manner, which maintains their right to dignity, privacy, independence and choice. They have the freedom to choose what they do and when they do it and any restrictions are agreed as part of their on-going care plan. Aids and equipment are provided to encourage maximum levels of independence and specialist advice and support is sought when necessary to achieve that aim. Examination of residents documentation and discussion with staff and management indicated that all residents are registered with a local doctor. Regular health checks and routine screening and treatments are offered by the practice and several residents see the practice nurse for blood tests and other advice and treatments. The doctor also offers residents regular vaccinations against flu and other illnesses and the decision as to whether or not to accept treatment is documented in the residents records. People are supported to make their own appointments with healthcare professionals and to attend these supported only minimally by staff. One resident returned from the doctors Evidence: surgery at the time of inspection where they had undergone blood tests by the Practice Nurse. The home has recently introduced a breast awareness check list for all female residents and this is completed by the key worker once a month. To facilitate this all female staff have attended breast awareness training. There are plans to identify a local Well Mans Clinic which will similarly identify male health issues. All residents have a person centred health passport which they take to appointments. This sets out in easy to understand terms any healthcare issues that affect the resident. There was evidence that residents also have regular dentistry, podiatry and attention to their vision and hearing and their attendance is appropriately recorded in the care records. A number of the residents are regular attendees at hospital. Details of the outcome of these appointments and any changes in treatment or medication are well documented in the care plans and daily records. The home has a medication policy in place with procedures and practice guidance for staff to follow. Since the last inspection there have been two medication errors which could have posed a risk to residents. These incidents were notified to the CSCI in Regulation 37 notifications . The staff that were responsible have since been retrained and assessed in medication administration procedures. There has been no further incidents since 19th August 2008. The arrangements for the recording, handling, safekeeping, administration and disposal of medicines received into the home were examined. The home has adopted the monitored dosage system for administration of medicines which helps to reduce the likelihood of drug error. Records of administration were up-to-date and accurate. However, the storage of a drug liable to misuse was not in line with current CSCI guidance. The Manager undertook to deal with the issue immediately therefore no requirement about this matter has been made in this report. Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The home has a complaints procedure, which is clear and accessible. Residents feel their views and comments are listened to and acted upon. Residents are protected from abuse and exploitation by well-trained, competent staff that demonstrate knowledge of the homes safeguarding adults and whistle-blowing policies. Evidence: The service has a complaints procedure which is clear and accessible to residents. It has been produced in user-friendly pictorial format to aid residents understanding. Residents are provided with information on how to make a complaint to the home, the time scale for response and the stages and process of the Organisations complaint procedure. Examination of the complaint records indicated that there have been two complaints made to the home since 1st January 2008. The details of the complaints were well documented. The complaints have been fully investigated by management and an outcome has been provided to the complainant. There has been no information about complaints about the service provided to the CSCI since the last inspection. There was evidence in staff files and from discussion with staff, that they receive training in safeguarding adults as part of their formal induction to the home. This learning is later consolidated when they undertake National Vocational Qualifications in which it forms a core module. Staff interviewed were aware of the homes whistleblowing policy and understood the importance of protecting residents from abuse and exploitation. There has been one safeguarding issue reported to the CSCI about this home since the last inspection concerning a choking incident, which resulted in the death of a resident. Evidence: This incident has been fully investigated by the Adult Protection Team in the Local Authority, the Police and the Coroner. As a result of recommendations made following the incident there has been a complete review of the accessibility of the kitchen, which is now kept locked. Risk assessments are now in place for all residents concerning the use of the kitchen. Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The physical design and layout of the home enables residents to live in a safe, well maintained and comfortable environment, which encourages independence. Evidence: A tour of the building evidenced that residents live in a warm and comfortable environment. All areas of the home were clean and hygienic. A toilet on the ground floor had no soap or towels but the Manager undertook to address this issue after the inspection. The home is tastefully decorated and is furnished in a modern and comfortable way. Communal areas were spacious, light and airy and were well used by residents at the time of inspection. The gardens were well kept. They are maintained weekly by professional gardeners. The home has a large patio and outside seating area and this year residents have planted a vegetable patch. One resident told the inspector they particularly liked barbeques that were a regular occurrence during the summer months. The home is well maintained and has the specialist equipment it needs to accommodate its residents. The home has been designed for small group living where residents can enjoy maximum independence in a discrete non-institutional environment. Residents are encouraged to see it as their own home and to add their own personal touches to the environment. The home is fully accessible to its current residents who are accommodated in single rooms on the ground and first floor. All bedrooms are furnished and decorated to a comfortable standard and they are individually personalised to meet the needs and preferences of the residents. There are suitably equipped bathrooms and toilets conveniently situated around the home. The laundry has appropriate facilities for the laundering of residents clothes and linens and there are appropriate infection control measures in place to protect residents from harm. Evidence: Residents commented on the quality of the decor and furnishings in the home. Comments such as Its lovely here, very homely and Ive got a lovely room with all my own things were made to the inspector. Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Residents are provided with care and support by a team of well trained and caring staff that have been robustly recruited. Evidence: Examination of five staff files and discussion with staff and management indicated that all necessary checks are undertaken on prospective staff to ensure the safety and protection of residents. Records were well kept and met the required standard. Advertisements for staff are placed in the job centre, on the Organisations website and in local newspapers. Currently there are no shortages of applicants and therefore no reliance on agencies to cover gaps in the roster. The interview process is systematic and includes set questions for candidates, scenarios and interview rating scales. Examination of the staff files and training records evidenced that most of the current staff have either gained or are in the process of attaining NVQs at levels 2, 3 & 4. The Registered Manager has already achieved an NVQ 4 in care and management. Staff say that the Manager is eager to provide support to the staff teams development and assists and guides people that are on the NVQ program. They say that there is plenty of opportunity to do training courses to further enhance their knowledge and skills and that they have access to refresher core skills training as well as more specialised training such as non-violent crisis intervention, medication administration, epilepsy, cultural awareness, Valuing People and The Mental Capacity Act. The homes Manager undertakes regular audits of the training records and identifies future training needs and requirements linked to fulfilling the business and financial plan for the home. Records indicate that all staff have been properly inducted and complete a period of shadowing more experienced staff to ensure they are confident and competent to carry Evidence: out the tasks of the job. Staff confirmed that they complete a Common Induction Standards workbook within their first 12 weeks of employment. All new staff are subject to a six month probationary period during which their skills are fully assessed. The staff records were well kept and contained copies of induction training, job descriptions, application form, two written references, training certificates and proof of identity. Records indicated that all staff are supervised 4 - 6 weekly and appraised on an annual basis. The following comments were made to the inspector about the qualities of staff. One residents said, the staff are good here and another said brilliant staff they are helpful and kind, I particularly like my key worker. Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The home is safe and well managed by a competent Manager and professional staff team. The home seeks and focuses on the views of its residents on an on-going basis. Evidence: The Registered Manager - Suzie Holton has been in post for two years and is highly regarded by the residents. Staff say she is an effective and popular leader who runs the home in an open manner which values the thoughts and opinions of staff and residents. The home has an ethos of being person centred and staff have been recruited and trained to a high standard to support the aims and objectives of the home. Quality Assurance is monitored through regular residents meetings, staff meetings, key worker meetings and monthly auditing of the home by Senior Management during Proprietors Representative visits (Regulation 26 visits). There is also an Organisational quality assurance audit annually and the items listed in the action plan are reviewed and reported on every three months. The Organisation is proactive in promoting and empowering its residents. Two of the current residents have been provided with a My Choice advocate who is based at Upton Hospital. The remainder of the residents have friends and family who will advocate on their behalf. Residents confirm that they feel management is approachable and will listen to their views, comments and suggestions and will act upon them appropriately. This was evidenced in the minutes of residents meetings and in the daily records. Evidence: Service users individual plans are regularly reviewed and up-dated at least every six months, this enables development and progress toward goals to be formally assessed and recorded. Examination of a sample of health and safety records indicated that all necessary checks and servicing of equipment is routinely undertaken to safeguard the health and welfare of people using the service. Unnecessary risks to residents are identified using comprehensive risk assessment. So far as possible the risks are reduced or eliminated by putting in place effective guidelines, policies and procedures. Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone : 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web:www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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